Gerber Life Final Expense Insurance
Contracting Application
Highest Commissions – Guaranteed!
Agent contracting ‐ highest commissions ‐ Gerber Life Final Expense. Call NAAIP direct
at 1‐800‐770‐0492 for appointment. Alternatively, complete the attached application and sign where indicated.
Fax or email your completed application along with copies of all insurance licenses for the states in
which you will be soliciting business.
Please fax or email pages back to us that you have written on. Include your state insurance license(s),
declaration page of your E and O insurance and void check. Void check must have pre‐printed bank information ‐
otherwise letter from the bank.
Agents will be Contracted at the Highest Commission Level.
Call NAAIP Agent Services before filling out this PDF for a higher
contract.
1-800-770-0492
Agent contracting - Gerber Life - highest commissions.
Please go to
http://www.hellosign.com
to electronically fill out the contract. Hellosign is free.
Gerber Life Forms, Rates, Applications and Videos
Go to
www.naaip.org
to learn about our free agent websites with 3 quote engines
and our free lead program. Monday thru Thursday conference call at Noon ET.
2014 Commission Schedule Click Here
Indicate with an x, which address is to be used for mailing purposes:
o
Home Addresso
Business AddressEmail Address:
________________________________________________________________________________________
(NOTE: By providing your e-mail address and/or fax number and/or engaging in electronic communications, you are consenting to
engaging in electronic communications with Gerber Life, unless such consent is expressly revoked).
License information:
Enclose a clear and current license for each state where you seek to be appointed by Gerber Life.
Florida non-resident producers, list each county where you propose to sell insurance:
____________________________________
(Attach a separate sheet, if necessary)
Errors and Omissions Insurance Information:
E&O coverage is with ___________________________________ (Carrier Name), with Limits of $___________________________ and a $_________________________Deductible. I will promptly notify Gerber Life of any cancellation or modification of coverage. (NOTE: Your signature on this Questionnaire affirms your agreement to maintain Errors & Omissions insurance covering the sales and service of Gerber Life insurance policies.
Background Experience: (Please read and answer each question carefully.)
1) Have you ever been fined, suspended, placed on probation or had a license revoked, paid administrative penalties, entered into a consent order, been issued a restricted license or otherwise been disciplined or reprimanded, or are you currently
under investigation by any insurance department, FINRA, the SEC or any other regulatory authority?. . . o Yes o No 2) Have you ever been convicted or plead guilty or nolo contendere (no contest) in connection with any offense,
served any probation, paid any fines or court costs, for any offense other than a minor traffic violation?. . . o Yes o No 3) Have you ever been short in account with any insurance company or employer?. . . o Yes o No 4) Have you ever had an application for bond declined?. . . o Yes o No 5) Have you ever filed for bankruptcy?. . . o Yes o No (Provide a separate document with a written explanation and applicable supporting documentation (i.e. court documents, insurance department documents, etc.) for any questions to which you responded “yes.” Please be sure to date and sign the written explanation.)
New York Producers Only: I have read New York Circular Letter No. 8, dated July 11, 1991, regarding Placement of Health Insurance Coverage with Unlicensed and Unauthorized Multiple Employer Welfare Arrangements, and agree to comply with its contents if applicable.
All Producers: I will retain a copy of any written disclosures of compensation provided to purchasers, as required by New York regulation or the regulation of any other state.
PUBLIC LAW 91-508 requires that we advise you that a routine inquiry may be made of your friends, neighbors and business associates during our initial or subsequent processing which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the inquiry, if one is made, will be provided. CERTIFICATION: I represent and warrant the answers to the above questions and requests for information are true. I agree to comply with all policies and procedures of Gerber Life and any applicable laws and regulations. I understand that I have a continuing obligation to disclose to Gerber Life any changes with respect to the responses provided in this Questionnaire including, but not limited to, my Background Experience.
Gerber Life Insurance Company (“Gerber Life”)
Producer Information Questionnaire
Gerber Life Insurance Company
1311 Mamaroneck Avenue, Suite 350, White Plains, NY 10605 www.gerberlife.com
®
Insurance Producer Name: ___________________________________________________________________________________ Citizen of U.S.: o Yes o No
(If no, please provide proof of eligibility to work in the U.S.) Date of Birth: _______________________
Social Security Number: ________________________________ Home Phone:
_______________________________________
Home Address: ____________________________________________________________________________________________
(Must be a street address)
Business Entity Name: _________________________________________ Tax ID#:______________________________________ Business Address: __________________________________________________________________________________________
(Must be a street address)
Business Phone: _______________________________ Business Fax: ________________________________________________
(Please print clearly and complete all questions, where applicable)
Print Name _________________________________Signature__________________________________ Date____________
x
ed. 4/2010
FAIR CREDIT REPORTING ACT DISCLOSURE TO CONSUMERS
AND BACKGROUND INVESTIGATION CONSENT FORM
Gerber Life Insurance Company (“Gerber Life”) and/or its agent may obtain Consumer Reports and/or other background
information as part of an evaluation of your eligibility for appointment as an insurance producer.
“Consumer Reports” means written, oral or other communication of any information by a consumer reporting agency
bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or
mode of living used by Gerber Life and/or its agent, in whole or in part, for the purpose of serving as a factor in
establishing your eligibility to be appointed as an insurance producer.
By signing below, I acknowledge that the Producer Information Questionnaire has been provided to me and will provide
Gerber Life and/or its agents with additional information that may be used in connection with my background
investigation.
CANDIDATE’S STATEMENT – READ CAREFULLY
I, ___________________________, hereby authorize Gerber Life and/or its agent to obtain, share, and review, as part of
my background investigation, in order to determine my eligibility to be appointed as an insurance producer, my credit
report, background information, references, information as to my general reputation, personal characteristics and mode of
living, past employment, education, criminal or police records, and government agency records, including information
maintained by both public and private organizations and public records.
I release Gerber Life and/or its agent and any person or entity which provides information pursuant to this authorization
from any and all liabilities in regards to the information obtained.
AUTHORIZATION
I authorize any consumer reporting agency, government agency, law enforcement agency, the National Association of
Securities Dealers, the Securities and Exchange Commission or any other person or organization having any records, data
or information concerning my background investigation, including, but not limited to, my credit history, public record
information, insurance license, regulatory action history or criminal record history to furnish such records, data and
information to Gerber Life and/or its agent.
I understand that, if appointed, this authorization will remain valid as long as I am appointed with Gerber Life.
A photocopy of this authorization shall be considered as effective as the original.
_____________________________________
__________________
Candidate
Signature
Date
_____________________________________
Print Full Name
Gerber Life Insurance Company (“Gerber Life”)
Producer Short Form
(To be used by agent if currently appointed to Gerber Life in the state where business will be transacted)
Producer Name
: _____________________________________________________General Agency Name: _________________________________Date of Birth: _______________
Social Security Number
: __________________________ Business Phone: ___________Individual Business E-mail address: ________________________________
(NOTE: By providing your e-mail address and/or fax number and/or engaging in electronic communications, you are consenting to engaging in electronic communications with Gerber Life, unless such consent is expressly revoked).
I represent and warrant the answers to the above questions are true. I agree to comply with all policies and procedures of Gerber Life and any applicable laws and regulations. I understand that I have a continuing obligation to disclose to Gerber Life any changes.
Gerber Life Insurance Company
1
AGENT AGREEMENT
PARTIES TO THE AGREEMENT
This Agreement is made and entered into between Gerber Life Insurance Company, hereafter referred to as “Company”, and________________________________________________________________, hereafter referred to as “Agent.”
In consideration of the following terms and conditions, this Agent Agreement (“the Agreement) is between Company and Agent effective as of the Effective Date stated on the last page of this agreement;
The Company hereby appoints the Agent to represent it subject to the following mutually agreed upon terms and conditions.
I. RESPONSIBILITIES OF THE PARTIES
The Agent Agrees to:
A. Licensing. Obtain and maintain and provide copies of all necessary licenses and regulatory approvals to perform the services under this Agreement.
B. Solicit Applications. Solicit applications for Company’s Products. C. Service Customers. Agent shall provide service to Agent’s customers.
D. Suitability. Ensure that each sale of the Company’s Products covered by this Agreement which is proposed or made directly by Agent is appropriate for and suitable to the needs of the insured and the person or entity to whom Agent made the sale, at the time the sale is made, and suitable in accordance with applicable law governing suitability of insurance products.
E. Company Policies, Procedures, Processes & Rules. Comply with all policies, practices, procedures, processes, and rules of Company. Agent shall promptly notify Company if Agent or any of its employees is not in substantial compliance with any Company policy, procedure, process or rule.
F. Comply with Laws and Regulations. Comply with all applicable laws and regulations and act in an ethical, professional manner in connection with this Agreement, including, with respect to any compensation disclosure obligations and any other obligations it may have governing its relationship with its customers.
G. Remittance of Monies. Treat any money received or collected for the Company as property held in trust, and promptly remit such money to Company at its administrative office in Fremont, Michigan. Agent shall not commingle any funds received or collected for the Company with its own funds. Agent must report any known violations of this provision.
H. Underwriting & Issue Requirements. Comply with the underwriting and issue requirements of the Company as well as any and all applicable legal requirements of the state or states in which the Agent does business.
I. Hold Harmless. Hold harmless and indemnify the Company from all losses, expenses, costs and damages resulting
from any acts by the Agent which breach the terms of this Agreement.
J. In Force Policies. Assist the Company in keeping its insurance policies in force.
K. Error & Omissions Insurance. Have and maintain Errors and Omissions liability insurance coverage on Agent and Agent’s employees during the term of this Agreement, in an amount and nature, and with such carrier(s) or on a self-insured basis, satisfactory to Company, and to provide evidence of such insurance to Company upon request. L. Document & Money Delivery. Adhere to all Company requirements including those related to policy application,
illustration (if any), and delivery of policies and the forwarding of any premium collected once a policy is approved. M. Product Familiarity. Be familiar with all provisions and benefits under each Product offered by the Company for
which Agent solicits applications and representing such Product accurately and fairly to prospective purchasers. N. Training. Participate in training to ensure that Agent is familiar with all provisions and benefits under each Product
offered by the Company and representing such Products accurately and fairly to prospective purchasers.
Gerber Life Insurance Company
8
PLEASE PRINT OR TYPE
.
In consideration of the covenants in this Agreement it is agreed and accepted to by:
Complete Section A only if the Agent is contracting with the Company as an individual, in which case, all Agent level
compensation will be paid to the Agent as an individual. Complete Section B only if the Agent is incorporated and this contract is between the Company and the Agent’s corporation (in which case, all Agent level compensation will be paid to the
corporation unless the Agent completes a separate Agent contract as an individual with the Company).
SECTION A SECTION B
______________________________________ ___________________________________ Individual Agent Name (Print or Type) Corporate Agent Name (Print or Type)
______________________________________ ___________________________________ Signature of Agent Signature of Authorized Officer
______________________________________ ___________________________________ Social Security Number Name of Authorized Officer (Print or Type) ___________________________________ Federal Tax Identification Number
Home Office Use
Signature of Gerber Life Insurance Company Officer______________________________________________ This contract shall take effect on ___________________________________ and subsequent contract years shall begin with the anniversary of this date.
Vendor Legal Name
DBA / Trading Name
(if applicable)
Address
City
State/Province/Region
Country
County
Postal / Zip Code
Telephone Number
Fax Number
Contact Name:
Vendor Legal Name
DBA / Trading Name
(if applicable)
Address
City
State/Province/Region
Country
County
Postal / Zip Code
Telephone Number
Fax Number
Tax ID / Reg Number
Enter 9 digit Federal ID or Social Security # for Individual
Subject to 1099 Reporting: ___Yes ___No
Vendor Headquarter / Corporate (must be physical address)
Vendor Financial Information
Complete if payment should be remitted to address different than above
Form
W-9
(Rev. December 2011) Department of the Treasury Internal Revenue ServiceRequest for Taxpayer
Identification Number and Certification
Give Form to the requester. Do not send to the IRS.
Print or type
See
Specific Instructions
on page 2.
Name (as shown on your income tax return)
Business name/disregarded entity name, if different from above
Check appropriate box for federal tax classification:
Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶
Other (see instructions) ▶
Exempt payee
Address (number, street, and apt. or suite no.) City, state, and ZIP code
Requester’s name and address (optional)
List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Social security number
– –
Employer identification number
–
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 4.
Sign
Here Signature of U.S. person ▶ Date ▶
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Purpose of Form
A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners’ share of effectively connected income.
Note. If a requester gives you a form other than Form W-9 to request
your TIN, you must use the requester’s form if it is substantially similar
to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, • An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or
business in the United States are generally required to pay a withholding
tax on any foreign partners’ share of income from such business.
Further, in certain cases where a Form W-9 has not been received, a
partnership is required to presume that a partner is a foreign person,
and pay the withholding tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the United
States, provide Form W-9 to the partnership to establish your U.S.
status and avoid withholding on your share of partnership income.
ACH INFORMATION FORM
Company Information
Company Name__________________________________________________________
Address ___________________________________________________________
Tax Identification Number ___ ___ - ___ ___ ___ ___ ___ ___ ___
Social Security Number ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Page | 15
Agent Compliance Manual originally approved September 3, 2010 Revision Date: May 9, 2013
COMPLIANCE POLICY STATEMENT OF UNDERSTANDING
AGENT COMPLIANCE MANUAL
AGENT
I acknowledge receipt of the Gerber Life Insurance Company Agent Compliance Manual. I acknowledge that I have read
and understand the contents of the Compliance Manual and further understand that if I do not fully comply with the
Compliance Manual’s requirements, it will be deemed a breach of my contract and may result in, without limitation, the
termination of my contract with Gerber Life Insurance Company.
1. I understand and acknowledge the need for strict compliance with all applicable federal and state laws and
regulations regarding the solicitation, negotiation and sale of insurance, as applicable.
2. I understand that Gerber Life requires strict adherence to federal and state telemarketing rules and
I am to comply with the Vendor Guidelines of the Gerber Life’s Telemarketing Compliance Monitoring Program.
My signature below certifies the following: completion of the Do Not Call training, required Do Not Call record
retention and that all applicable telemarketing registrations are current and in compliance with the Vendor
Guidelines. I will review the Do Not Call training within 90 days of the date of initial contracting with Gerber Life
and annually thereafter. Note: This section only applies to vendors performing telemarketing activities on behalf of
Gerber Life.
3. I certify that I will remain in compliance with Gerber Life’s Compliance Training Program requirements, which may
include Money Laundering and other training requirements. I agree that it is my responsibility to take
Anti-Money Laundering training within 90 days of the date of initial contracting with Gerber Life and annually thereafter.
In addition, when requested, I agree to provide Gerber Life evidence of completion of the required trainings.
4. I certify that I have taken Anti-Money Laundering courses directly through another represented insurance company
or a competent third party within the past twelve months.
5. It is my responsibility to ensure that I am aware of, and abide by, the laws and regulations in all states of licensure
dealing with the use of professional certifications and designations, particularly when used with seniors.
6. Agent signatures are ONLY required at initial contract and thereafter will be signed by the agent’s General Agent. It
is my responsibility to read and comply with the Agent Compliance Manual and all updates even though the General
Agent will be signing this Statement of Understanding annually on my behalf.
7. I certify that I will comply with New York Regulation 194 Producer Compensation Disclosure.
__________________________________________________________________________
Signature Date
__________________________________________________________________________
(Print Name)
__________________________________________________________________________
Title
__________________________________________________________________________
Agency Name
PLEASE RETURN A SIGNED COPY OF THIS DOCUMENT WITHIN 30 DAYS FROM RECEIPTTO GERBER
GERBER LIFE PAYMENT HIERARCHY SCHEDULE
1.
INDIVIDUAL/ENTITY NAME: Identify the individual / entity being contracted.INDIV./ ENTITY NAME: __________________________________ SOC SEC/ TIN#:______________________
2.
ALREADY APPOINTED WITH GERBER LIFE:□
NO□
YES (If Yes GERBER LIFE AGENT# ___________ )3.
REPORT TO NAME: Identify the individual /entity in the hierarchy directly above the individual/entity being contracted.INDIV. / ENTITY NAME: ____________________________________ SOC SEC/ TIN#:________________________
4.
NMO/MGA NAME:_________________________________________ NMO/MGA GERBER LIFE #:_________________5.
ROLE: Identify the role of the contracted individual /entity:□
General Agent□
Sub-GA□
Writing Agent6.
TYPE OF REQUEST:□
New individual / entity□
Hierarchy change□
Schedule change□
Additional Appointment(s)7.
APPOINTMENT REQUEST:
Indicate the state(s) the contracted individual/entity is to be appointed in.GERBER LIFE INSURANCE
: AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA
MA ME MD MI MN MS MO MT NC ND NE NH NJ NM NY NV OH OK
OR PA RI SC SD TN TX UT VA VT WA WI WV WY
8.
PRODUCT / COMPENSATION: Identify the level of compensation by placing an “X” in the box above the appropriateselection. All rates listed are First Year Compensation + First Year Expense Allowance = %Total First Year Compensation. NOTE: The Writing Agent cannot be paid more than the Writing Agent Maximum Compensation at Level 4 indicated by and *.
Select Level with
corresponding %’s
□
4*
□
3
□
2
□
1
□
0
Grow Up FA<$24,999 FA>$24,999 40+5=45 55+0=55 40 55 35 50 30 45 0% 0% Guaranteed Life 35+25=60 55 50 45 0% College Plan Maturity 10 -15 yrs Maturity 16- 20 yrs 5+ 5 = 10 5+13=18 0% 0% College Plan Single Premium 5 Years of Premium 3 + 0 = 3 4 + 0 = 4 0% 0% Accident Protection FA=$100,000 FA<$100,000 50+0=50 35+0=35 0% 0%Term Life Insurance 55+5=60 55 50 45 0%
Whole Life Insurance 55+5=60 55 50 45 0%
I agree to have Gerber Life pay the named Individual/Entity the Commission Level indicated in the above schedule.
_______________________________ ____________________________________ Corporate Agent Name (Print or Type) Signature of Authorized Officer
____________________________ ____________________________________ Date Signed Name of Authorized Officer (Print or Type)
